How we work with ACC

ACC has two categories of cover which are treated differently by both ACC and Southern Cross.

1. Personal injury caused by accident (PICBA)
2. Treatment injury.

Southern Cross health insurance policies do not provide cover for accident treatment or treatment injury expenses that ACC is legally responsible for. However, in some cases ACC will not pay the full amount charged for treatment. In these cases a member may be able to make a claim under their policy.

Personal injury caused by accident (PICBA)

If a member is declined by ACC and the treatment they require is eligible under their Southern Cross policy, Southern Cross may provide payment for that claim. The following steps outline how to apply for this:

The member must send us a copy of their decline letter from ACC and the ARTP (Assessment Report and Treatment Plan).

Once we receive the above documents, we issue prior approval.

The claim is released for payment once received.

No cover will be approved until we receive ACC's decline letter. Any treatment required prior to an ACC decision will not be covered by Southern Cross as it's classified as acute.

We also need members to undertake a review in cases where the surgery appears causally linked to a personal injury caused by an accident (as opposed to degeneration or other factors). Southern Cross will help members through all stages of the review process.

Treatment injury

Occasionally, a patient receives an unexpected injury during treatment or surgery. According to the Accident Compensation Act 2001, a treatment injury is caused as a result of treatment from a registered health professional, and that's not an ordinary consequence.

ACC is the "first insurer" for such injuries. For more information, visit ACC's 'Treatment Injury' page. ACC is legally responsible for the costs of treatment injury, but to make things easier for members, Southern Cross may pay for the treatment and recover the costs from ACC, provided the following criteria are met:

The member has returned a member consent form which allows Southern Cross to process the ACC claim on the member's behalf.

ACC has confirmed to Southern Cross that the potential treatment injury claim has been received.

If ACC declines the treatment injury claim

Please ensure your patient sends Southern Cross a copy of the ACC decline letter or treatment injury decision, because we might want to review the decision with ACC. We'll consult with the member on all reviews we do.